Provider Demographics
NPI:1578801684
Name:CORREA, MICKEY (LCSW, MDIV)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:
Last Name:CORREA
Suffix:
Gender:M
Credentials:LCSW, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 BUSH ST
Mailing Address - Street 2:APT. 1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-1762
Mailing Address - Country:US
Mailing Address - Phone:718-483-5829
Mailing Address - Fax:
Practice Address - Street 1:65 BUSH ST
Practice Address - Street 2:APT. 1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11231-1762
Practice Address - Country:US
Practice Address - Phone:718-483-5829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082796104100000X
NY0810481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker